Background: Conjunctival autografting in pterygium surgery without the use of sutures and fibrin glue is being practiced by some surgeons recently. The present study was undertaken to evaluate the outcome of the procedure. Methods: This retrospective study was conducted by reviewing the records of thirty-five consecutive cases of pterygium surgery with sutureless and glue-free conjunctival autografting done by a single surgeon from February 1, 2017, to April 30, 2017. One patient had nasal and temporal pterygium, and all other patients had primary nasal pterygium. Under peribulbar block, pterygium was excised and autologous conjunctival grafting was performed without sutures or fibrin glue. Grafts were taken from superior bulbar conjunctiva. Postoperative follow-up was done on the 1st and 7th postoperative day and then after 1 month and 2 months. Results: Patients who had graft recession, graft edema, subconjunctival hemorrhage, and dellen during immediate postoperative period eventually settled down, and the cosmetic outcome was good in all patients. Except one, in all other cases, grafts were in situ. None of them had recurrence till the last follow-up. Conclusion: Sutureless glue-free conjunctival autografting in pterygium surgery takes short surgical time, is economic, and has good cosmetic outcome.

Pterygium is a triangular fold of conjunctiva encroaching upon the cornea. It can occur from either side within the interpalpebral fissure.[1] Nasal pterygium is more common than temporal pterygium. The exact cause of pterygium is not known. Exposure to ultraviolet (UV) rays is perhaps the most common risk factor for the occurrence of pterygium.[2],[3],[4],[5] UV ray-induced localized stem cell dysfunction is possibly related to the formation of pterygium.[6] Pterygium occurs with increasing frequency in climate approaching the equator. Other causes include continuous exposure to dry and dusty environment. The subconjunctival tissue undergoes elastotic degeneration and proliferates as vascularized granular tissue under the epithelium which ultimately encroaches cornea. This process causes redness, irritation, and visual disturbance due to irregular corneal astigmatism. In severe cases, if the pterygium extends to the visual axis, it can block the vision altogether. Surgery is indicated when there is reduced vision due to astigmatism or encroachment of the visual axis, recurrent inflammation, and for cosmesis.

Bare scleral excision of pterygium results in a significantly higher recurrence rate than excision accompanied by the use of certain adjuvants. Conjunctival or limbal autograft is superior to amniotic membrane graft surgery in reducing the recurrence rate. Currently, the best surgical option in terms of recurrence is conjunctival autograft. In conjunctival autografting after pterygium excision, the graft is usually sutured or glued to the bed using fibrin glue to secure its position. Suturing requires considerable skill from the surgeon associated with the prolonged operation time, postoperative discomfort, and suture-related complications. With fibrin glue, there is a risk of hypersensitivity reaction and viral transmission and is expensive.[7] These problems lead to the development of sutureless and glue-free conjunctival autografting technique.

When tissue is wounded, blood comes in contact with collagen triggering blood platelets to begin secreting inflammatory factors.[8] Fibrin and fibronectin crosslink together and trap proteins. This forms the main structural support for the wound until collagen is deposited. Migratory cells use this as a matrix to crawl across. This physiological process is made use of in this technique. The conjunctival graft is placed onto the bed where the oozing blood clots and forms a bioadhesive which secures the graft in its position. The present study was undertaken to evaluate the outcome of the technique of sutureless and glue-free conjunctival autografting using patients' own blood to secure the graft in place.

Methods

Medical records of 35 consecutive patients who underwent sutureless glue-free conjunctival autografting with pterygium surgery done by a single surgeon at Aarthy Eye Hospital, Karur, between February 1, 2017, and April 30, 2017, were reviewed. All patients had primary pterygium [Figure 1]. Thirty-four patients had nasal pterygium and 1 had nasal and temporal pterygium.

Under peribulbar block, after placing the speculum, superior rectus bridle suture was applied and not clamped. Pterygium area was mopped dry and the part to be excised marked using marker pen. Pterygium was excised starting from the body, and the head was stripped off by reverse avulsion. The remnants were cleared using Took's knife. If bleeding was more, cautery was used. Scleral bare area was measured. The superior rectus bridle suture was clamped to expose the superior bulbar conjunctiva. After mopping dry, graft area was marked 1 mm larger than bare scleral area in both dimensions. Conjunctiva was ballooned by injecting saline subconjunctivally. Conjunctival graft was dissected carefully avoiding Tenon's capsule and without button holes using non-toothed forceps and round-tipped scissors. After clearing the recipient bed of excess blood, the graft was placed on the bare scleral area in such a way that limbal side of the graft overlies the limbus of the scleral bare area. Once properly positioned, the graft was left undisturbed for 3 min. After mopping excess blood, antibiotic eye ointment was applied. Speculum was removed gently without disturbing the graft and patch applied. Patch was removed after 24 h, and antibiotic and steroid drops were prescribed [Figure 2]. The patch was not disturbed for 24 h. All patients were examined after 24 h and followed up after 1, 4, and 8 weeks for graft edema, subconjunctival hemorrhage, graft retraction, dellen, and recurrence of pterygium [Figure 3].

A total of 35 eyes of 35 patients with primary pterygium were included in this study. The mean age of the studied population was 40 ± 1. The male and female distribution was 5:30 [Table 1]. Out of 35 eyes, 4 had subconjunctival hemorrhage, 2 had dellen, 1 had graft loss, and 2 had graft recession [Table 2]. At 8 weeks' follow-up, no recurrence was found. All patients had good cosmetic outcome.

Pterygium surgery should ideally be easy to perform, cost-effective, and cosmetically acceptable with no recurrence. Several surgical techniques have evolved over the years. Bare scleral technique was the one that was introduced first. This has been abandoned due to high recurrence rate.[9] Application of intraoperative mitomycin C had serious complications with scleral melt and ocular perforation.[10] Currently, conjunctival autografting is the standard procedure for pterygium surgery with low recurrence rate.[11] The graft was usually fixed to the scleral bed using sutures. However, this procedure involves prolonged surgical time, postoperative discomfort, and other suture-related complications. To overcome these difficulties, fibrin glue application to fix the graft in place was developed.[7] However, this has disadvantages such as higher cost, anaphylactic reaction, and risk of viral transmission. To overcome these drawbacks, conjunctival autografting using patient's own blood to secure the graft in place has been introduced recently. This technique has overcome several disadvantages encountered with earlier methods. The technique is easier to perform with less discomfort to patients and is cost-effective.

In our series, one case had lost graft due to excessive bleeding which could be attributed to surgeon's learning curve. Patients who had dellen and graft recession eventually settled down. The cosmetic outcome was good in all the patients. No recurrence was found, but the follow-up period was only 2 months. The result was comparable to other studies using similar technique.[12] Sutureless glue-free conjunctival autografting with pterygium surgery is an excellent technique, easy to perform, with short surgical time, good cosmesis, and no recurrence.

Earlier studies have shown that calcium accelerates the rate of fibrin monomer polymerization, thereby decreasing the time required to form clot.[13] Studies may be undertaken in the future to find whether addition of calcium to the scleral bed helps in faster and better adherence of the conjunctival graft.

Conclusion

Sutureless glue-free conjunctival autografting in pterygium surgery takes short surgical time, is economic, and has good cosmetic outcome.